Top

European Journal of Trauma and Emergency Surgery

Published in:

Open Access 14-12-2022 | Tibia Fracture | Original Article

Prediction of distal tibial articular extension in tibial shaft fractures: both posterior malleolar fracture and non posterior malleolar fracture intra-articular extension

Authors: Darren Myatt, Howard Stringer, James Chapman, Ben Fischer, Lyndon Mason

Published in: European Journal of Trauma and Emergency Surgery | Issue 2/2023

Abstract

Background

Multiple authors have highlighted the increased incidence of occult posterior malleolar fractures (PMFs) with spiral tibial shaft fractures, although other reported associated risks of intra-articular extension have been limited. The aim of our study is to investigate both PMFs and non-PMFs intra-articular extensions associated with tibial diaphyseal fractures to try to determine any predictive factors.

Methods

We undertook a retrospective review of a prospectively collected database. The inclusion criteria for this study were any patient who had sustained a diaphyseal tibial fracture, who had undergone surgery during the study period and who had also undergone a CT scan in addition to plain radiographs. The study time period for this study was between 01/01/2013 and 9/11/2021.

Results

Out of 764 diaphyseal fractures identified, 442 met the inclusion criteria. A total of 107 patients had PMF extensions (24.21%), and a further 128 patients (28.96%) had intra-articular extensions that were not PMF’s. On multivariate analysis, spiral tibial fracture subtypes of the AO/OTA classification (OR 4.18, p < 0.001) and medial direction of tibial spiral from proximal to distal (OR 4.38, p < 0.001) were both significantly associated with PMF. Regarding intra-articular fractures, multivariate analysis showed significant associations with non-spiral (OR 4.83, p < 0.001) and distal (OR 15.32, p < 0.001) tibial fractures and fibular fractures that were oblique (OR 2.01, p = 0.019) and at the same level as tibia fracture (OR 1.83, p = 0.045) or no fracture of the fibular (OR 7.02, p < 0.001).

Conclusion

In our study, distal tibial articular extension occurs in almost half of tibial shaft fractures. There are very few fracture patterns that are not associated with some type of intra-articular extension, and therefore, a low threshold for preoperative CT should be maintained.

Level of evidence

Larsen P, Elsoe R, Hansen SH, Graven-Nielsen T, Laessoe U, Rasmussen S. Incidence and epidemiology of tibial shaft fractures. Injury. 2015;46(4):746–50. https://doi.org/10.1016/j.injury.2014.12.027.CrossRefPubMed

Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–7. https://doi.org/10.1016/j.injury.2006.04.130.CrossRefPubMed

Emami A, Mjoberg B, Ragnarsson B, Larsson S. Changing epidemiology of tibial shaft fractures. 513 cases compared between 1971–1975 and 1986–1990. Acta Orthop Scand. 1996;67(6):557–61. https://doi.org/10.3109/17453679608997755.CrossRefPubMed

Bengner U, Ekbom T, Johnell O, Nilsson BE. Incidence of femoral and tibial shaft fractures. Epidemiology 1950–1983 in Malmo, Sweden. Acta Orthop Scand. 1990;61(3):251–4. https://doi.org/10.3109/17453679008993511.CrossRefPubMed

Weiss RJ, Montgomery SM, Ehlin A, Al Dabbagh Z, Stark A, Jansson KA. Decreasing incidence of tibial shaft fractures between 1998 and 2004: information based on 10,627 Swedish inpatients. Acta Orthop. 2008;79(4):526–33. https://doi.org/10.1080/17453670710015535.CrossRefPubMed

Mitchell PM, Harms KA, Lee AK, Collinge CA. Morphology of the posterior malleolar fracture associated with a spiral distal tibia fracture. J Orthop Trauma. 2019;33(4):185–8. https://doi.org/10.1097/BOT.0000000000001398.CrossRefPubMed

Boraiah S, Gardner MJ, Helfet DL, Lorich DG. High association of posterior malleolus fractures with spiral distal tibial fractures. Clin Orthop Relat Res. 2008;466(7):1692–8. https://doi.org/10.1007/s11999-008-0224-5.CrossRefPubMedPubMedCentral

Hendrickx LAM, Cain ME, Sierevelt IN, Jadav B, Kerkhoffs G, Jaarsma RL, Doornberg JN. Incidence, predictors, and fracture mapping of (occult) posterior malleolar fractures associated with tibial shaft fractures. J Orthop Trauma. 2019;33(12):e452–8. https://doi.org/10.1097/BOT.0000000000001605.CrossRefPubMed

Hou Z, Zhang Q, Zhang Y, Li S, Pan J, Wu H. A occult and regular combination injury: the posterior malleolar fracture associated with spiral tibial shaft fracture. J Trauma. 2009;66(5):1385–90. https://doi.org/10.1097/TA.0b013e31817fdf0a.CrossRefPubMed

10.

Wang Z, Chen W, Zhu Y, Tian S, Zhao K, Guo J, Hou Z, Zhang Q, Zhang Y. Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review. J Orthop Surg Res. 2021;16(1):355. https://doi.org/10.1186/s13018-021-02502-6.CrossRefPubMedPubMedCentral

11.

Kempegowda H, Maniar HH, Richard R, Tawari A, Jove G, Suk M, Beebe MJ, Han C, Tornetta P 3rd, Kubiak EN, Horwitz DS. Posterior malleolar fractures associated with tibial shaft fractures and sequence of fixation. J Orthop Trauma. 2016;30(10):568–71. https://doi.org/10.1097/BOT.0000000000000629.CrossRefPubMed

12.

Hendrickx LAM, Sobol GL, Langerhuizen DWG, Bulstra AEJ, Hreha J, Sprague S, Sirkin MS, Ring D, Kerkhoffs G, Jaarsma RL, Doornberg JN, Machine Learning C. A machine learning algorithm to predict the probability of (occult) posterior malleolar fractures associated with tibial shaft fractures to guide “malleolus first” fixation. J Orthop Trauma. 2020;34(3):131–8. https://doi.org/10.1097/BOT.0000000000001663.CrossRefPubMed

13.

Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018;32(1):S1–170. https://doi.org/10.1097/BOT.0000000000001063.CrossRefPubMed

14.

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.CrossRefPubMed

15.

Huang Z, Liu Y, Xie W, Li X, Qin X, Hu J. Pre-operative radiographic findings predicting concomitant posterior malleolar fractures in tibial shaft fractures: a comparative retrospective study. BMC Musculoskelet Disord. 2018;19(1):86. https://doi.org/10.1186/s12891-018-1982-1.CrossRefPubMedPubMedCentral

16.

Jung KJ, Chung CY, Park MS, Chung MK, Lee DY, Koo S, Lee KM. Concomitant ankle injuries associated with tibial shaft fractures. Foot Ankle Int. 2015;36(10):1209–14. https://doi.org/10.1177/1071100715588381.CrossRefPubMed

17.

Sobol GL, Shaath MK, Reilly MC, Adams MR, Sirkin MS. The incidence of posterior malleolar involvement in distal spiral tibia fractures: is it higher than we think? J Orthop Trauma. 2018;32(11):543–7. https://doi.org/10.1097/BOT.0000000000001307.CrossRefPubMed

18.

Wang D, Yang J, Dong X, Zhou S, Wang C. Incidence and predictive factors of tibial fracture with occult posterior ankle fractures. J Healthc Eng. 2021;2021:4392595. https://doi.org/10.1155/2021/4392595.CrossRefPubMedPubMedCentral

Title: Prediction of distal tibial articular extension in tibial shaft fractures: both posterior malleolar fracture and non posterior malleolar fracture intra-articular extension
Authors: Darren Myatt
Howard Stringer
James Chapman
Ben Fischer
Lyndon Mason
Publication date: 14-12-2022
Publisher: Springer Berlin Heidelberg
Keyword: Tibia Fracture
Published in: European Journal of Trauma and Emergency Surgery / Issue 2/2023
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-022-02156-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Prediction of distal tibial articular extension in tibial shaft fractures: both posterior malleolar fracture and non posterior malleolar fracture intra-articular extension

Abstract

Background

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Level of evidence

Please log in to get access to this content

Other articles of this Issue 2/2023

Lateral para-olecranon approach: surgical guide and anatomical considerations to the anconeus branch: is there a nerve-free zone?

Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems

Early outcomes of surgically managed civilian gunshot femur fractures at a level one trauma unit in Cape Town, South Africa: a retrospective review

Perioperative outcome of minimally invasive stabilisation of bilateral fragility fractures of the sacrum: a comparative study of bisegmental transsacral stabilisation versus spinopelvic fixation

Health-related quality of life after severe trauma and available PROMS: an updated review (part I)

Management and short-term outcomes of patients with small bowel obstruction in Denmark: a multicentre prospective cohort study